Physiological Breech Birth Training Resource Booklet

Shawn Walker, RM PhD

& the Breech Birth Network Collective

breechbirth.org.uk Contents

Physiological Breech Birth Algorithm

Nomenclature: Types of Breech

‘Normal for Breech’ – The Mechanisms

Complicated Breech Births

Evidence Update

Building Expertise

Photography / Film Agreement

Reference List

Become a trainer

Rights of use:

The slides included in this booklet are the copyrighted property of Breech Birth Network, Community Interest Company, and Shawn Walker, RM PhD, unless otherwise indicated. They are provided for personal use only, for those who have attended Physiological Breech Birth Training provided by the Breech Birth Network CIC. No permission is given to copy or distribute the materials.

The algorithm and photography/film agreement may be copied and used (CC BY-ND 4.0). E- mail [email protected] for electronic copies.

On-line resources can be accessed via the Breech Birth Network Vimeo site. No permission is given to share the site address and password, and any sharing on a public forum would be considered a violation of copyright. Please do use the videos for teaching purposes, but also help us to safeguard the privacy of women and health care professionals who share their vulnerability with us so that others can learn.

https://vimeo.com/album/4810021 password: HeadsUp!101

Illustrators

Merlin Strangeway – https://www.drawntomedicine.com Kate Evans – http://www.cartoonkate.co.uk Mariamni Plested – https://www.carnelianseeker.com

1 61. 8. - – 136(2):151 . 20(2): 25 20(2): . Rocking Rocking fetal head fetal / forceps Lithotomy Lithotomy Gynecol Spontaneous Spontaneous J birthexpected 177. 662.e9 9. - - Int ? and rotate back rotate and episiotomy Release anterior arm arm anterior Release Perineal sweep / / sweep Perineal - 31(3):e170 The Practising Midwife cesareans 211(6):662.e1 . 44(2):101 . Birth Birth. 14. realign thumbs - nd avoid No interference No Gynecol a Guide head Guide into pelvis & & pelvis into below clavicle below Designed by Shawn Walker, RM PhD RM Walker, Shawn by Designed Shoulder press, Shoulder Women & th professionals. Obstet Quiet, calm, support warm © 2018 Breech Birth Network, 2018 © breechbirth.org.uk (on side baby faces) baby side (on Am J Midwifery34:7 . pushing Sweep down anterior arm arm anterior down Sweep . Continuous Scoop & flex forehead flex & Scoop 6. 209. - - cleavage fingers Midwifery43:1 . shoulder girdle grip girdle shoulder . 45(2):202 . Birth YES & Rotate ‘Tum to Bum’ Sternal crease / / crease Sternal below clavicle below Shoulder press, Shoulder Rotation using flat hands / / hands flat using Rotation Elevate occiput occiput Elevate Maternal Maternal buttock lift buttock start Running maternal movement pelvis – - Encourage spontaneous spontaneous Encourage P diameter P - P diameter P - or outlet / pelvic inlet pelvic No rotation rotation No effective in A Pelvis & shoulders shoulders & Pelvis deflexed or delayed delayed or deflexed Steady progress & progress Steady Rotation Fetal head extended at at headextended Fetal remain in A in remain birth of pelvis of birth If not immediately immediately not If Fetal head in mid in head Fetal Incomplete Incomplete Effectiveness of vaginal breech birth training strategies: an integrative review of the literature. the of review integrative an strategies: training birth breech vaginal of Effectiveness

Reassuring fetal heartrate fetal Reassuring

anterior begins begins anterior / not known

3 mins 3 Rotation to sacrum < after

Standards for maternity care professionals attending planned upright breech births Principles of physiological breech Principles of physiological birth practice: A Delphi Study. Deliberate acquisition of competence in physiological breech birth: A grounded theory study. theory grounded A birth: breech physiological in competence of acquisition Deliberate Expertise in physiological breech birth: A mixed methods study. methods mixed A birth: breech physiological in Expertise NO

5 mins 5 < <

Cope O, Cochrane V (2017) breech Physiological birth: Evaluation of a training programme for bir -

7 mins 7 < < (2017) P Parker M, M (2017) M A et al (2014) Does pregnancy create and/or positions moreshifting room in a woman’s pelvis?

Bisits

diameter) Scamell

M, Parker P (2016) P Parker M, M, Parker P (2016) P Parker M, M, Parker P (2017) P Parker M, -A,

contractions Scamell E,

umbilicus head (bitrochanteric (bitrochanteric Re: Encouraging spontaneous maternal movement, breech teams, breech birth in water Re: Training based on mechanisms, videos, upright birth position Re: Teaching physiological breech as ‘complex normality’, increasing breech births Re: Breech teams, understanding mechanisms, team review of births Re: Breech teams, breech specialists, increasing the rate of vaginal breech birth, generative expertise

Re: Manoeuvres used for physiological breech births, maintaining case records, initial resuscitation with umbilicus intact

perineum perineum between between

buttocks buttocks

Birth of the the of Birth Birth of the the of Birth visible on the the on visible

F, F, Daviss B, KC,Johnson Reitter A (2017) Does breech delivery instead ofin an on the upright position back improve outcomes Birth of the the of Birth Breech remains remains Breech Physiological Breech Birth Algorithm Birth Breech Physiological Walker S, Scamell Walker S, Scamell Walker S, Reading C, Silverwood Walker S, Breslin Louwen Walker S, Scamell Additional References: B Daviss A, Reitter Physiological Breech Birth Algorithm References Algorithm Birth Breech Physiological This algorithm is free to use, provided it is used unchanged and one of the following publications is referenced: P, Parker S, Walker

2 3 Variations of Breech Presentation

Frank Breech

Hip joints flexed, knees extended

Physiological Breech Birth

Flexed Breech What is Complete

Both hip joints flexed, both knees flexed ‘normal for breech’? Understanding the

mechanisms

Shawn Walker, RM PhD Incomplete Updated March 2019

Both hip joints flexed, one knee flexed, one knee extended Image by Leah Sandretzky, Closer to my Heart, 2012

‘Dropped Foot’ in labour

One hip flexed, one hip extended Please respect women’s privacy

• Do not take photographs of slides which contain pictures Kneeling Breech of women

One or both hips extended, one or both knees flexed and presenting • Do not share images on the https://vimeo.com/album/4810021 internet Password: HeadsUp!101

• Informational slides may be Standing / Footling Breech photographed and shared

Illustrations by Kate Evans for Breech Birth Network, CIC breechbirth.org.uk

4 5 Physiological Breech Birth Algorithm © 2018 Breech Birth Network, breechbirth.org.uk Different Breech Paradigms Designed by Shawn Walker, RM PhD Steady progress & No interference Reassuring fetal heartrate YES Quiet, calm, warm support 7 mins between between Complex Normality Abnormality perineum contractions visible on the < Breechremains Physiological breech birth has an All breech presentations are observable ‘normal’ mechanisms ‘abnormal’ v Normal = happens >50% of the time, resulting 5 mins diameter)

in a spontaneous, healthy birth < buttocks buttocks (bitrochanteric (bitrochanteric

“Spontaneous breech birth is of the Birth very rare, usually only preterm” Identifying mechanism helps to (PROMPT 2012)

determine when help is needed, 3 mins the the <

and when the birth should remain Birth of undisturbed Therefore, assistance to deliver umbilicus the arms and head is routinely applied Requires additional training Birth of the head the © 2011 Breech Birth Network CIC © 2011 Breech Birth Network CIC

“Watching Videos” ‘Normal Breech Birth’ P1, previous inducted ND, induction at 38/40 (oligohydramnios)

Video 012: ‘Learning Lithotomy’ Video 011

6 7 A Birth Centre

Breech Birth Thank you to Midwife Jennifer Gallardo and the Andaluz Waterbirth Center

Positive support and preparation in pregnancy

Thank you to Midwife A foot has slipped down due to the increased Jennifer Gallardo and the Incomplete breech / Andaluz Waterbirth Center space beneath the sacrum – No need to for the use of these photos ‘Drop-Foot’ Breech © 2011 Breech Birth Network CIC panic! © 2011 Breech Birth Network CIC

Optimal hormonal physiology in labour: Rotation The effect of environment is not The breech engages and negligible! descends sacro-transverse

Thank you to Midwife Jennifer Gallardo and the Andaluz Waterbirth Center for the use of these photos Thank you to Midwife Jennifer Gallardo and the Andaluz Waterbirth Center

8 9 Both legs are born and the shoulders have descended past the The mother uses ischial spines. a birthing stool to assist the birth. Now gravity is able to do its work, gently bringing the baby down further. This continued progress should be noticeable even between contractions.

Thank you to Midwife Jennifer Gallardo and the Andaluz Waterbirth Center Thank you to Midwife Jennifer Gallardo and the © 2011 Breech Birth Network CIC Andaluz Waterbirth Center © 2011 Breech Birth Network CIC

Baby’s back extends as she is being born to enable the Spontaneous rotation as extended leg to be born the anterior arm drops spontaneously. beneath the pubic arch.

Mother leans forward. This This rotation is caused by enables: the head entering the pelvis in the oblique/transverse 1. Baby’s birth to be in line with diameter. the forces of gravity

2. Maximum space in the pelvic outlet as the shoulders Thank you to Midwife descend Jennifer Gallardo and the Andaluz Waterbirth Center Thank you to Midwife © 2011 Breech Birth Network CIC Jennifer Gallardo and the © 2011 Breech Birth Network CIC Andaluz Waterbirth Center

10 11 Rotating back to SA/OA once the head has realigned to occipito- anterior in the pelvis. Baby’s hand slips beside her ear as her face is born. Baby’s left elbow is visible at the introitus. Gravity continues to assist the gradual birth of the head, while Failure to rotate back after birth of midwife’s hands are poised to the anterior arm should alert you to break the fall. a potential problem with the head.

Thank you to Midwife Thank you to Midwife Jennifer Gallardo and the Jennifer Gallardo and the Andaluz Waterbirth Center Andaluz Waterbirth Center

The meaning of a natural Baby appears to be keeping her birth varies from person own head flexed! to person. The chin and the forearm are visible Some women and families behind the cord. value it highly and are strengthened by such a Perhaps a compound presentation birth experience. is only a problem if it causes a delay?

In this birth, it seems to be assisting. Thank you to Midwife Jennifer Gallardo and the Andaluz Waterbirth Center Thank you to Midwife Jennifer Gallardo and the © 2011 Breech Birth Network CIC © 2011 Breech Birth Network CIC Andaluz Waterbirth Center

Individualised evaluation

… and had a very unique placenta, which appreciated the lack of intervention in this birth.

Blog: Dolicocephaly

14 15 ‘normal for breech’ 2: Internal rotation to sacrum transverse • Labour begins spontaneously at • Dilating the soft birth canal • Asynclitic (noticeable if a VE is done) or near term • Occiput also rotates to • Not uncommon to rotate in long arc transverse; shoulders A-P through posterior when beginning in • Average-sized baby RSP • Feet alongside (flexed) or above bottom (legs extended) • Progresses straightforwardly • Unambiguously reassuring

Mechanisms of Breech Birth Flexed breech: Internal rotation to sacrum transverse Frank (Extended) Breech in LSA position “Respect the Mechanism” #1: Engagement • Sacrum anterior oblique or directly anterior (LSA or RSA)

Main reference: Frye A, 2004 (with changes from observational experience and consultation with other practitioners)

Picture: Privileged to be with Midwives Jane Evans and Anne Frye at the International Breech Birth Conference, Washington DC, November 2012. Jane has written extensively about her observations of breech mechanisms, based Thank you to Jennifer Gallardo and the Andaluz Waterbirth Center for use of these photos. on decades of clinical experience. © 2011 Breech Birth Network CIC © 2011 Breech Birth Network CIC

16 17 © 2018 Breech Birth Network, breechbirth.org.uk Physiological Breech Birth Algorithm Designed by Shawn Walker, RM PhD Breech Vaginal Examinations? between 7 mins < contractions visible on the Breechremains • Nulliparous woman, frank breech presentation perineum • Back on the right, deeply engaged on palpation • 8 cm, presenting part at +1

• By extension and lateroflexion of < contractions visible on the Breechremains the spine perineum • Dilating the perineum 5 mins <

• Anterior buttock leads diameter) (bitrochanteric (bitrochanteric buttocks buttocks Birth of the

Once the breech is visible at the perineum ... • you should see regular progress, especially with each contraction, but many women push in between Increased risk of cord compression after ‘point of no return’ is reached Images: Dr David Hayes • and Shawn Walker Birth of the head the © 2011 Breech Birth Network CIC

18 19 ‘Normal’ for the flexed breech 4: Birth of the buttocks Blog: ‘Running start’

Anterior buttock Squatting back onto heels Spontaneously rising, appears first opens pelvic outlet as pelvic thrust forward bitrochanteric diameter – protects perineum Physiological birth attendants passes through as buttocks are born, This baby is presenting with one leg flexed ‘read’ spontaneous maternal and one leg extended up movements as meaningful and opens inlet to admit Image: Shawn Walker This ‘dropped foot’ baby extended a leg down when the fetal pelvis descended into the sacral space useful to optimal process Do not interfere ... shoulders Image: Dr Anke Reitter © 2011 Breech Birth Network CIC © 2011 Breech Birth Network CIC ‘Fetal ejection reflex’

© 2018 Breech Birth Network, breechbirth.org.uk #4: Birth of the buttocks Physiological Breech Birth Algorithm Designed by Shawn Walker, RM PhD 7 mins between between perineum contractions visible on the < Breechremains 5 mins 5 mins diameter) diameter) < < (bitrochanteric (bitrochanteric buttocks buttocks buttocks buttocks (bitrochanteric (bitrochanteric Birth of the Birth of the of the Birth 3 mins the the < Birth Birth of umbilicus Birth of the head the Birth of the head the Thank you to Midwife Pamela Qualls LM © 2011 Breech Birth Network CIC and the mother for use of this photo.

Steady progress & Reassuring fetal heartrate between 7 mins Encourage spontaneous / not known < NO

contractions maternal movement visible on the Breechremains perineum 5 mins < diameter) buttocks (bitrochanteric (bitrochanteric Birth of the 3 mins < umbilicus Birth of the See Blog: ‘Running Start’ Birth of the head the Image: Courtesy of the mother © 2011 Breech Birth Network CIC

© 2018 Breech Birth Network, breechbirth.org.uk Physiological Breech Birth Algorithm Designed by Shawn Walker, RM PhD 4: Birth of the buttocks Steady progress & Reassuring fetal heartrate Anterior and then posterior buttock, by lateral spinal flexion between 7 mins Encourage spontaneous Continuous / not known < NO

contractions maternal movement pushing visible on the Breechremains

perineum When rotation begins, it should be ‘Tum to Bum’ 5 mins < diameter) buttocks (bitrochanteric (bitrochanteric Birth of the “Just breath … Wait 3 mins

22 23 5: Internal/external rotation What do you think? External rotation Internal rotation • Sacrum anterior - ‘Tum to Bum’ • Shoulders transverse • Occiput anterior Typical pre-training survey results:

Shoulders engage (flexion) as umbilicus is born

5: Internal/external rotation 6: Birth of the legs • By extension of spine Fresh, • May occur at any point before or If they deliver slowly (one at a time), be toothpaste during the birth of the arms alert for problems with the arms. meconium = Rotation ‘normal for ‘tum to breech’ bum’

24 25 6: Birth of the legs 7 mins between between perineum contractions visible on the < Breechremains

birth of umbilicus 5 mins diameter) < buttocks buttocks (bitrochanteric (bitrochanteric Birth of the of the Birth 3 mins the the <

Birth Birth of Blog: Arms – umbilicus Identifying the need to intervene Should occur simultaneously or within a few seconds. Thank you to Midwife Normal May need help Birth of

7: Descent of the torso Frank/Extended breech: Legs should be born simultaneously or within a few seconds of each other • Brief period of rest may occur after birth of the legs All breech births: Arms should be born simultaneously or within a few seconds of each other • Spontaneous descent should resume promptly, even between contractions. Arms should be born with next contraction

‘Tum to Bum’ Dr Jenny Davidson, PhD

Blog: Arms – Identifying the need to intervene Images: Dr Michael Hall

26 27 ‘Valley of the Cord’ • Sternal crease • Cleavage / Canalillo • = Arms are not entrapped behind the head • You can anticipate the spontaneous birth of the arms shortly • Just visible under the Needs help (Partially rotated / perineum Normal Anterior arm in front of head)

Incomplete breech (foot/bottom) presentation Video 004: Flexed breech birth – not a footling!

Needs help Normal (No rotation / Anterior arm behind head) Thank you to Midwives Pamela Qualls and Mary Cronk, and the mothers, for Photographs © 2013 Shawn Walker © 2011 Breech Birth Network CIC use of these photos. © 2011 Breech Birth Network CIC

28 29 8: Birth of the arms (simultaneously) Variation: Birth of anterior arm and shoulder • Lateral spinal flexion • Head may rotate to engage oblique or • Occasional slight rotation to left or right transverse as the shoulders reach the outlet

Thank you to Midwife Pamela Qualls LM and the mother for use of these photos.

Physiological Breech Birth Algorithm © 2018 Breech Birth Network, breechbirth.org.uk Designed by Shawn Walker, RM PhD Birth of the anterior arm as the head rotates to engage Steady progress & No interference Reassuring fetal heartrate YES Quiet, calm, warm support 7 mins between between perineum contractions visible on the < Breechremains Rotation as the head Rotation to sacrum Spontaneous Sternal crease / anterior begins birth engages in the pelvis. cleavage after birth of pelvis expected

5 mins Avoid handling the diameter) < buttocks buttocks (bitrochanteric (bitrochanteric

Birth of the of the Birth umbilical cord as it may spasm. 3 mins the the < Note condition of the cord. Birth Birth of umbilicus

30 31 10: Birth of the head Baby’s tummy crunch promotes flexion Unflexed head – more likely with a • By flexion – enhanced by baby’s tone and compromised baby A neurologically intact baby moves in ways that assist his/her own birth. movements Elevate occiput to achieve flexion Walker S, Scamell M, Parker P (2016) Principles of physiological breech birth practice: A Delphi study. Midwifery 43:1-6. • After birth of arms, chin is visible at perineum Spine enters head at the base of the occiput

Video 013: Tummy Thank you to NZ Midwife Sharon Weir and the mother for the use of this video. Crunch of Champions

9: Internal/external rotation Breech Mechanisms: Dr Michael Hall • Begins before and completes after posterior ... then shoulders rotate externally with the arm is born to bring occiput anterior head to bring their long axis transverse • Slight movement to left or right as posterior • Breech is now in line with head, sacrum arm is born – anterior (‘Tum to Bum’) Brown meconium = lower threshold for intervention

Video 014: Mechanisms of Breech Birth

32 33 When both feet come first ... Document

Colour Tone Cord Heart Rate (if you can visualise fetal chest)

P.S. Don’t wipe! You may stimulate involuntary clenching of the pelvic floor muscles.

Thank you to Jennifer Gallardo and the Andaluz Waterbirth Center; and Nilaya and her Mum; for the use of these photos. Thank you to Midwife Joy Horner and the mother for use of these photos. © 2011 Breech Birth Network CIC © 2011 Breech Birth Network CIC

Foot/Knee Presentation Water Many women breech assume a happens … slightly reclined position.

Baby half out, still slightly Sacro-posterior descent, Assistance needed to posterior premature extraction of achieve rotation knee/foot Thank you to Midwife Susan Gill and the mother for use of these photos. • Kneeling breeches usually descend in direct sacro-posterior – do not panic! • Rotation occurs on the pelvic floor • Premature extraction will result in the need for further interventions to assist mechanisms

34 35 52% of an experienced panel had attended breech births in water. Breech in Water Walker, Scamell & Parker, Principles of physiological breech birth practice (2016)

Thank you to Midwife Susan Gill and the mother for use of these photos. Breech in Water

Slight rotation clock-wise to After birth of the anterior The midwife assists the baby sacrum-oblique as the arm, rotation back to to the surface following birth anterior arm is born under sacro-anterior. Gravity of the head. the maternal pubic arch. does have some effect in

52% of an experienced panel had attended breech births in water. Breech in Water Walker, Scamell & Parker, Principles of physiological breech birth practice (2016)

Normal mechanisms: the Rotation to sacrum-anterior Buoyancy assists the birth of fetal pelvis is born sacrum Video 004: Flexed transverse. occurs with the first push the legs when mother is breech birth – not a Thank you to Rebecca Kauffeld of after the fetal pelvis is born. reclined. footling! oneblessedmomma.com and her midwives for use of these photos. © 2011 Breech Birth Network CIC © 2011 Breech Birth Network CIC

36 37 Complicated Breech Births First principle: Avoid complications by enabling and encouraging maternal How and when to help active breech births movement Spontaneous changes of posture Shawn Walker RM PhD create up to 2 cm more space in the Last update: maternal pelvis!

March 2019 Reitter, A., Daviss, B.A., Bisits, A., Schollenberger, A., et al (2014) Does pregnancy and/or shifting positions create more room in a woman`s pelvis? AJOG 211 (6): 662.e1-662.e9 , 2017 Artwork by Tina St John Ontario Midwife Illustration: Merlin Strangeway : . She Shack Girl Birthing Series © Tina St John © 2018 Breech Birth Network CIC © 2011 breechbirth.org.uk Enquiries tinastjohn@gmail com

© 2018 Breech Birth Network, breechbirth.org.uk Physiological Breech Birth Algorithm Designed by Shawn Walker, RM PhD Maternal Manoeuvres – active breech birth Steady progress & No interference Reassuring fetal heartrate YES Quiet, calm, warm support 7 mins

< Encourage spontaneous contractions visible on the NO / not known Breech remains remains Breech maternal movement Video 001: perineum between ‘Give it a wiggle’ 5 mins < diameter) buttocks buttocks (bitrochanteric Birth of the Birth 3 mins < umbilicus Birth of the Birth

38 39 Squatting back to open the pelvic outlet “Restore the Mechanism” Understanding the optimal mechanisms of a physiological breech birth is the key to determining how and when to help.

In a physiological breech birth, a healthy, uncompromised baby moves in ways which assist his/her own birth Do not disturb! Video 005: (100% consensus) Video 004: ‘Birth of Leliana’ ... unless intervention is ‘Flexed Breech’ required. Principles of physiological breech birth practice: A Delphi study Walker, Scamell & Parker, Midwifery 2016

Maternal Manoeuvres – active breech birth Evaluating Fetal Well-being

Video 011: ‘Normal breech birth’

Forward-leaning on a birthing stool, as in the Video 005: image to the right, opens the ‘Birth of Leliana’ pelvic outlet (like kneeling squat) and aligns the birth canal with the effects of gravity. Thank you to Midwives Monika Boenigk and Jennifer Gallardo, and the Andaluz Waterbirth Center

40 41 © 2018 Breech Birth Network, breechbirth.org.uk The perineum Physiological Breech Birth Algorithm Designed by Shawn Walker, RM PhD Steady progress & YES No interference • Breech = most episiotomies Reassuring fetal heartrate Quiet, calm, warm support

7 mins Encourage spontaneous Continuous Perineal sweep / NO / not known < maternal movement pushing

contractions episiotomy visible on the

• Also most intact perineums! remains Breech perineum between • When to consider intervening:

– Fetal compromise 5 mins < diameter) buttocks buttocks (bitrochanteric – Perineum extending with breech and of the Birth causing delay

– Buttonhole tears 3 mins < umbilicus – Be wary of CTG once baby has of the Birth descended

© 2018 Breech Birth Network, breechbirth.org.uk Physiological Breech Birth Algorithm Designed by Shawn Walker, RM PhD Birth of the buttocks Steady progress & • When rotation begins, it should be ‘Tum to Bum’ Reassuring fetal heartrate between

7 mins Encourage spontaneous Continuous • If not you should gently encourage rotation to a sacro-anterior position, NO / not known < maternal movement pushing contractions visible on the Breech remains remains Breech using the pelvic girdle – like Woods’ Corkscrew Manoeuvre perineum • Work with the contraction – rotation not traction 5 mins < diameter) buttocks buttocks (bitrochanteric Birth of the Birth

42 43 Extended Legs Initiate Resuscitation on the cord 4.7 kg extended breech baby being born spontaneously on a birthing stool DCC was shown to maintain oxygenation if the onset of pulmonary respiration was Frank breech legs should be born within a delayed or impaired. On the other hand, a Thank you to Jennifer few seconds of each other. Gallardo and the significant 25% decrease in oxygen Andaluz Waterbirth Flex the extended leg by pressing two fingers Center for use of this saturations was observed when applying ICC photo. in the popliteal fossae, flexing the extended leg under the same physiological conditions. We towards the baby’s abdomen. conclude that DCC has a significant impact on newborn hemodynamics, mainly because of Spontaneous delivery of the limbs and the improved blood volume and the sustained trunk is preferable. (PROMPT) placental respiration.

Cord conditions

Thank you to Midwife Pamela Qualls LM and the mother for use of these photos.

Ideal = 3 minutes from birth of umbilicus to birth of the head

44 45 Arms Potential problems with the arms: crawling out

Normal Full rotation (‘tum to bum’) Mid-pelvis Inlet Partial rotation, into oblique diameter No rotation, shoulders in A-P diameter after birth of umbilicus Blog: Arms – = anterior arm caught on ischial spine = arm(s) caught on pelvic inlet Image: Shawn Walker Identifying the Image: Dr Anke Reitter Image: Dr Emiliano Chavira Normal need to intervene Thank you to midwives Pam Qualls and May need help Mary Cronk, and the mothers for © 2011 breechbirth.org.uk permission to use these photos. © 2011 breechbirth.org.uk

Normal = Arms born within a few seconds of each other Potential problems with the arms: Video 008: crawling out ‘Undiagnosed Home Birth’

46 47 © 2018 Breech Birth Network, breechbirth.org.uk Physiological Breech Birth Algorithm Designed by Shawn Walker, RM PhD Training Video 2017: Sweeping down the arms 7 mins < contractions visible on the Breech remains remains Breech perineum between

5 mins Incomplete Running < diameter) Rotation start buttocks buttocks (bitrochanteric Birth of the Birth 3 mins

< See Blog: umbilicus Birth of the Birth ‘Running Start’

Incomplete Running Sweep down anterior arm

Partial rotation only 7 mins Rotation start (on side baby faces) < contractions visible on the Breech remains remains Breech Anterior arm is: perineum between

• closest to pubic arch 5 mins < diameter)

• on the side baby faces buttocks (bitrochanteric Birth of the Birth

Sweep across the body to 3 mins

“Restore the Mechanism” < umbilicus Birth of the Birth Normal Video 009: Full rotation (‘tum to bum’) ‘Frankfurt, Needs help after birth of umbilicus Sept 2017’ Partial rotation, into oblique diameter = head Image: Shawn Walker anterior arm caught on ischial spine

48 49 Applying the principles to lithotomy birth Foot/Knee Presentation, primip, 37.6 BMI

Sacro-posterior descent No progress with contraction (note mec) Nudging shoulder blade to encourage rotation

Learning from each birth: Video 049: ‘Grand multipara, undiagnosed Using ‘flat hands’ on Do not wait for the next home birth’ shoulder girdle to assist contraction if you have rotation with contraction diagnosed delay / abnormal – no traction mechanisms. Restore the mechanism with prayer Waiting for contraction hands and rotation. © 2011 breechbirth.org.uk © 2011 breechbirth.org.uk

Flat Hands / Prayer Hands Nuchal Arm: No Rotation, Shoulders in A-P

‘Because if you need to use them you’re praying ...’

Used for rotational manoeuvres (arms)

Thank you to Midwives • Avoid soft tissue damage by even Pamela Qualls and Joy pressure with fingertips and palms of Horner, and the mothers, hands for use of these photos.

• Maintain alignment of the head and cervical spine (fingertips)

• Failure to rotate back (‘tum to bum’) after birth of umbilicus is sign of dystocia Normal Needs help Anterior arm caught on pubic bone

50 51 Nuchal Arm: No Rotation, Shoulders in A-P Rotational Manoeuvres & Nuchal Arms

Normal

No rotation – 7 mins Rotation using prayer hands Release anterior arm Pelvis & shoulders

< / shoulder girdle grip and rotate back contractions visible on the remain in A-P diameter Breech remains remains Breech perineum between 5 mins < diameter)

Thank you to Mary Cronk, buttocks (bitrochanteric

MBE, and the mother for of the Birth permission to use these photos. 3 mins < umbilicus Birth of the Birth

52 53 Third stage begins when the uterus is empty. Recumbent position Images Remember: : Anne Frye, 2004 (used with permission) The focus is on rotation, No benefit from delay in not traction. helping at this point

Only enough traction to keep the spine straight.

Delay with second arm = delay with head

• After the legs are born, expect progress to resume even before the next contraction. • If the arms are born very slowly (>a few seconds between arms), or progress stops with the baby facing you, it may be because the head has not engaged. • Sweep down the second arm

54 55 © 2018 Breech Birth Network, breechbirth.org.uk Physiological Breech Birth Algorithm Designed by Shawn Walker, RM PhD between 7 mins < contractions visible on the Breech remains remains Breech perineum UMBILICAL CORD INTACTUMBILICAL 5 mins < diameter) buttocks buttocks Initiateresuscitationwith (bitrochanteric Birth of the Birth 3 mins

< Fetal head extended at

umbilicus pelvic inlet Birth of the Birth in A-P diameter head

Extended Head at Inlet Diagnose: Assisting engagement of the head • Baby is sacro-/occipito-anterior • ‘Bird beak’ instead of a chin at the pelvic inlet

Problem: • Sinciput (forehead) is caught on sacral promontory • Cannot flex without being lifted • May need to be rotated to enter pelvis in oblique/transverse diameter • Reverse brow presentation (fronto-occipital diameter)

Solution: Elevate & rotate Blog: Dolicocephaly • Supporting baby’s body weight, fingers elevate occiput as in M-S-V • Rotate into transverse or oblique if needed • Guide into pelvis and flex/shoulder press to deliver Video 006: Alternative: “Restore the Mechanism” ‘Head • Ask the woman to shuffle back towards you, while supporting the Entrapment’

56 57 RCOG Guidelines (2006) Assisting engagement of the aftercoming head “Restore the Mechanism”

“[T]he head was just … was fixed …. It was in a direct occiput-anterior position, so you know, baby’s out, Elevate & Rotate is a recognised manoeuvre, but is not specifically taught in sacrum is anterior …. and what eventually was most breech training programmes successful in dislodging it was kind of replacing the Potential complications from lack of understanding: head or elevating the head off the pelvic inlet a little bit • Delay/further hypoxia • Cervical spine damage (eg. Burns Marshall, ‘wait for the nape ...’) and just turning it transverse so that it could enter the • Forceps injuries (when applied to extended/impacted head) • Occipital diastasis (forcing an impacted head through the pelvis) pelvis, and then it delivered quite easily.” • Dislocated jaw (from pulling when head is impacted) (Obstetrician, standard lithotomy delivery) • Skull crush (from aggressive suprapubic pressure on impacted head) • Cervical head entrapment (including previously fully dilated cervix)

Thank you to Dr Priscila Huguet and Narrative reflection Rotation to assist engagement the mother for use of this video.

“[A]s she stood, I just automatically put my knee up to the baby’s body to kind of support the baby … And it was weird, as I put my knee up, I felt the head lift and flex because I had my fingers in place at the same time … the knee under his bottom was an instinctive manoeuvre … But as it happened, then I realised what was happening … I was like, ‘Oh, God … this is what [Midwife Expert] was talking about!’” (Midwife, upright birth) © 2011 breechbirth.org.uk © 2011 breechbirth.org.uk

58 59 © 2018 Breech Birth Network, breechbirth.org.uk © 2018 Breech Birth Network, breechbirth.org.uk Physiological Breech Birth Algorithm Designed by Shawn Walker, RM PhD Physiological Breech Birth Algorithm Designed by Shawn Walker, RM PhD between 7 mins 7 mins < < contractions visible on the contractions visible on the Breech remains remains Breech Breech remains remains Breech perineum between perineum

Video 012: ‘Elevate and 5 mins UMBILICAL CORD INTACTUMBILICAL Rotate’ 5 mins < < diameter) diameter) buttocks buttocks buttocks buttocks (bitrochanteric Initiateresuscitationwith (bitrochanteric Birth of the Birth Birth of the Birth 3 mins 3 mins

< Fetal head extended at Guide head Elevate occiput < into pelvis &

umbilicus pelvic inlet umbilicus

Birth of the Birth & Rotate in A-P diameter realign of the Birth

Suprapubic Pressure Head and neck not visible Anus not dilated Mauriceau-Cronk Mauriceau-Smellie-Veit, with woman upright upside-down.

Crucial differences: • Uses gravity rather than slight traction on

, 2004 (used with permission) with (used 2004 , shoulders, reducing risk of cervical nerve damage • Can use upper jaw bone rather than cheek bones. Less risk of damage to Holistic Midwifery Holistic eyes. The second midwife has assisted the woman into an upright kneeling position • Can apply pressure from all fours. She uses the heel of one hand to apply pressure just above the . pubic bone, to encourage head flexion and/or rotation off the pubic bone. The through perineum midwife braces herself by applying counter-pressure on the woman’s sacrum.

60 61 Shoulder Press with fingers

2017 Training Video Ensure the head is aligned, chin central

Benefits: Video 004 • Quick, efficient, effective • Minimises risk of cervical nerve damage, pressure evenly distributed across chest below clavicle • Minimises risk of perineal damage by following path of birth canal

© 2018 Breech Birth Network, breechbirth.org.uk Physiological Breech Birth Algorithm Designed by Shawn Walker, RM PhD Shoulder Press with Video 003: ‘Rocking shoulder thumbs & rocking press’ 7 mins Thank you to Dr Priscila Huguet and < contractions visible on the

Breech remains remains Breech the mother for use of these videos. perineum between 5 mins < diameter) buttocks buttocks (bitrochanteric Birth of the Birth 3 mins < umbilicus Birth of the Birth “with rock & roll ...” Fetal head in mid-pelvis Shoulder press, or outlet / fingers Illustration: Merlin Strangeway deflexed or delayed below clavicle Blog: ‘Stop 4 Ashville Illustration: Merlin Strangeway head Birth of the Birth © 2011 breechbirth.org.uk © 2011 breechbirth.org.uk

62 63 © 2018 Breech Birth Network, breechbirth.org.uk Physiological Breech Birth Algorithm Designed by Shawn Walker, RM PhD 7 mins < contractions visible on the Breech remains remains Breech perineum between 5 mins < diameter) Video 005: buttocks buttocks (bitrochanteric Birth of the Birth ‘Birth of Leliana’ 3 mins < umbilicus Birth of the Birth

Fetal head in mid-pelvis Shoulder press, Shoulder press, or outlet / fingers thumbs Rocking fetal head deflexed or delayed below clavicle below clavicle head

© 2018 Breech Birth Network, breechbirth.org.uk Buttock Lift (when the perineum holds on) Physiological Breech Birth Algorithm Designed by Shawn Walker, RM PhD 7 mins < contractions visible on the Breech remains remains Breech perineum between 5 mins < diameter) buttocks buttocks (bitrochanteric Birth of the Birth 3 mins < umbilicus Birth of the Birth

Shoulder Press not Where has the nose Fetal head in mid-pelvis Shoulder press, Shoulder press, or outlet / fingers thumbs Rocking gone? Baby’s head has fetal head working: cannot get Knees-chest not helpful, deflexed or delayed below clavicle below clavicle baby far enough under receded, need to use

baby’s head extends head Shoulder Press & move If not immediately Maternal to pivot around the Illustration: Merlin Strangeway Birth of the Birth effective buttock lift symphysis © 2011 breechbirth.org.uk buttocks up and away. © 2011 breechbirth.org.uk

64 65 © 2018 Breech Birth Network, breechbirth.org.uk Physiological Breech Birth Algorithm Designed by Shawn Walker, RM PhD 7 mins < contractions visible on the Breech remains remains Breech perineum between 5 mins < diameter) buttocks buttocks (bitrochanteric Birth of the Birth 3 mins < umbilicus Birth of the Birth

Fetal head in mid-pelvis Shoulder press, Shoulder press, or outlet / fingers thumbs Rocking fetal head deflexed or delayed below clavicle below clavicle

Scoop & Flex Forehead Guidelines:

• Second leg born within a Dr Michael Hall few seconds of the first (Forceps Hands) • Second arm born within & a few seconds of the first

• Entire baby born within 5 Prof Betty-Anne Daviss minutes of fetal pelvis, 3 (Crowning Touch) minutes of umbilicus

http://rixarixa.blogspot.co.uk/2016/07/betty-anne-daviss-cardinal-movements.html See Also: http://rixarixa.blogspot.co.uk/2016/07/gail-tully-visualizing-obstructed.html © 2011 breechbirth.org.uk © 2011 breechbirth.org.uk

66 67 Your First Questions: Breech Birth •How are you feeling? Review of the New •What do you know about breech already? RCOG Guidelines •What is important to you about this birth? Dr Shawn Walker Midwife & PhD •What are your future family plans, if any? King’s College London

Candra Harjanto, wood, June 2016 breechbirth.org.uk breechbirth.org.uk

Counselling for ECV

Provide local/personal success rates where available. What the guideline doesn’t say: ECV improves the outcomes for babies.

breechbirth.org.uk breechbirth.org.uk

68 69 The Belfast Royal Victoria breech team: Obstetricians Niamh McCabe and Janitha Costa, and Breech Specialist Midwife Jacqui Simpson

breechbirth.org.uk breechbirth.org.uk

70 71 ECV / Breech Clinics What information is important to women & their partners? Lots of evidence for midwife practitioners Walker S, et al (2015). Standards for midwife practitioners of external Kok et al, 2008 - Expectant parents’ preferences for mode of delivery and cephalic version: A Delphi study. Midwifery trade-offs of outcomes for breech presentation (80 women & partners) Beuckens A, Rijnders M, Verburgt-Doeleman G, Rijninks-van Driel G, Thorpe J, Hutton E. An observational study of the success and complications of 2546 external cephalic versions in low-risk pregnant women performed by trained • Most important factors: ‘safest route for the midwives. BJOG 2016. baby’ and ‘fear for a handicapped child’ Uptake and success improves when • Women: most important information was 2-year practitioners perform ECV regularly neonatal outcome Andrews S, et al. Finding the breech: Influence of breech presentation on Midwifery lecturers of the Netherlands • Men: most important information was outcomes mode of delivery based on timing of diagnosis, attempt at external cephalic • Common curriculum version, and provider success with version. Birth. 2017 • Strong ECV practice base for women Bogner G, et al. Single-institute experience, management, success rate, and • Guidelines for midwives outcome after external cephalic version at term. Int J Gynaecol Obs. 2012 • 65% preferred caesarean section

breechbirth.org.uk breechbirth.org.uk

Counselling for Mode of Birth Information re: Mode of Delivery

Some women feel ECV is their only option

Watts NP, et al. This baby is not for turning: Women’s experiences of attempted external cephalic version. BMC Pregnancy Childbirth. BioMed Central; 2016

Impey et al, Management of Breech breechbirth.org.uk Presentation, RCOG Green-top Guideline, 2017 breechbirth.org.uk

72 73 Information re: Mode of Delivery Information re: the mother’s health

Information re: future babies

Impey et al, Management of Breech Impey et al, Management of Breech Presentation, RCOG Green-top Guideline, 2017 breechbirth.org.uk Presentation, RCOG Green-top Guideline, 2017 breechbirth.org.uk

Information re: the mother’s health Situations with increased risk

“Women with a first elective versus emergency cesarean have increased risk of severe complications in the second pregnancy.”

Impey et al, Management of Breech Impey et al, Management of Breech Presentation, RCOG Green-top Guideline, 2017 breechbirth.org.uk Presentation, RCOG Green-top Guideline, 2017 breechbirth.org.uk

74 75 Risks for future pregnancies - Vlemmix et al 2013 Variations of breech mechanisms

Complete or Footling?

Due to increased space under the sacrum, a complete (flexed/tailor sitting) breech can drop a foot or two down to emerge first, but the breech will be descending in the pelvis as well With a true footling presentation, the breech will remain high above the pelvic rim. Thank you to Jennifer Gallardo and the Andaluz Waterbirth Center for use of this photo. breechbirth.org.uk breechbirth.org.uk

BREECH MYTH: Breech birth is more risky for women Skilled intrapartum care having their first baby It is also noteworthy that parity, induction of labor, use of continuous electronic fetal heart rate monitoring, and use of epidural analgesia were not associated with higher or lower risk of adverse perinatal outcome. Factors associated with adverse perinatal outcome in the Term Breech Trial, Su et al, 2003

When comparing primiparous and multiparous women who actually gave birth vaginally, it was noted that breech infants of primiparous mothers received Apgar scores of <4 at one minute significantly more often (9.3 vs 0%; p = 0.010) than breech infants of multiparous women, but

there were no significant differences in the Apgar scores Impey et al, Management of Breech at five minutes …. There was no difference in NICU Presentation, RCOG Green-top Guideline, 2017 admittance or infant morbidity between the primiparous and multiparous delivery groups.

breechbirth.org.uk Toivonen et al, 2012 breechbirth.org.uk

76 77 BREECH MYTH: Breech birth is more risky when the Breech diagnosed in labour breech is diagnosed for the first time in labour

Reality: It is significantly more risky for the mother!

Approx 1:100-150 women presents in labour with an undiagnosed Every midwifery-led setting should have a plan breech

Heads Up Clinic, May 2012 – January 2014, birth rate = 2300 27/137 breech presentations undiagnosed (1:135 women) 18 caesarean section (67%); 9 vaginal breech births (33%) 22 admitted under Midwifery Led Care (81%)

Impey et al, Management of Breech Presentation, RCOG Green-top Guideline, 2017 breechbirth.org.uk breechbirth.org.uk

CS at full dilatation is most risky … for mum & baby! • Systematic review & meta-analysis (1st stage vs 2nd stage CS), many studies excluded heart rate anomalies (biased toward CS performed for delay).

When CS performed at full dilatation (compared to <10cm): • Mothers: 8 x more likely to die, 7 x more likely to be admitted to ICU, 9 x more likely to have an extended incision, 10 x more likely to have lower segment tears

• Neonates 5 x more likely to die, 6 x more likely to be injured, NICU rates comparable, Apgars comparable

Pergialiotis V et al, Eur J of Obstetrics & Gynecology and Reproductive Biology (2014)

breechbirth.org.uk breechbirth.org.uk

78 79 But what about the TBT? Intrapartum care In the TBT, the difference between outcomes for vaginal birth and CS performed after 3 cm was non-significant.

Impey et al, Management of Breech breechbirth.org.uk Presentation, RCOG Green-top Guideline, 2017 breechbirth.org.uk

Maternal birthing position

Impey et al, Management of Breech breechbirth.org.uk Presentation, RCOG Green-top Guideline, 2017 breechbirth.org.uk

80 81 Interventions for complications What does a breech specialist do?

• Counselling • Presentation diagnosis by USS • ECV/moxibustion • Support other maternity staff at breech births, planned or unplanned

Impey et al, Management of Breech Presentation, RCOG Green-top Guideline, 2017 • Teach updates at mandatory events and for students • Reflective review after breech births / study group • Risk management related to breech / Audit

Shoulder Press Picture credit: Dr Jacque Gerrard, RCM Image © Shawn Walker 2013 • Research and conferences breechbirth.org.uk breechbirth.org.uk

Organisation & Governance

Impey et al, Management of Breech Presentation, RCOG Green-top Guideline, 2017 breechbirth.org.uk

82 83 Breech Clinic Outcome 25 0 Building Local Breech Clinic 20 0 Breech Expertise VBB conference

15 0

ECV Clinic RCOG Breech Shawn Walker, RM, MA Study Day Breech Study Day RJMS November 2018 10 0

me deliver my daughter breech 0 last month with no c-section. 20 10/201 1 20 11/201 2 20 12/201 3 20 13/201 4 20 14/201 5 20 15/201 6 20 16/201 7 20 17/201 8 CS V BD EC V Line ar ( CS)

Vaginal Breech Deliveries Pre and post training Parity Gestation Royal Jubilee Maternity Services, Belfast 45% 70%

55%

45% Dr K. Johnston, Dr M. Heim, Dr G. Spence 25% 23% th 20% 30% 28 November 2018 15% 15% 15% 10% 9% 9% 9% 5%

23 - 23+6W 24 - +6W 25 - 27+6W 28 - 33+6W 34 - 36+6W >37W PRIMIGRAVIDA PAROUS

Pr e Tr aini ng Post Training Pr e Tr aini ng Post Training

84 85 NHS Resolution Report 2017 Fetal outcomes with VBB • Five years of cerebral palsy claims, 2012-2016 83% • Breech presentation = 12% of all claims • 2016 NHS Hospital statistics:

32% Breech = 0.4% of all births Breech training for the 24% 24% Regroupment Les Sages- • 5 / 6 claims were diagnosed femmes du Québec, Montreal 2017 late in labour APGAR<7 NNU ADM

Pr e Tr aini ng Post Training Magro, M. (2017) Five years of cerebral palsy claims. NHS Resolution.

Breech Clinic Success What is required …?

• Hands-on simulation (skills and drills) • Regular opportunities to discuss with peers and mentors • Watching breech birth videos • Theoretical instruction in anatomy, physiology, mechanisms and manoeuvres • Mentorship and supervision in clinical settings

I did a study day about 1 year ago in Wales with you both. I work in the community in What is expertise? Brecon, Powys. 4 weeks ago I attended a homebirth as a 2nd midwife and just as I • Skill and knowledge acquired through walked thru the door the Birthing mum was in the pool and a foot presented itself! training, practice and/or study Immediately I asked mum to stand up and step out the pool. As she did do the baby's • Generative expertise body birthed but he was in the lateral position. I remembered Shawn saying don't wait – comparatively good outcomes for the contraction to help the baby into position so having released his arms I pushed – more breech births him up under his bottom and tried to rotate him. after a couple of goes he was 'right'. – confidence of colleagues Mum was still standing at this point. I asked her to keep wiggling and then felt the • Alienating authority baby’s chin caught inside the cervix so I pushed it down with my finger and then did the – claims authority through experience shoulder press and he was born! he need rescue breaths but was ok. Thanks to your – fails to generate better outcomes, more Dr Anke Reitter teaching study day I felt I could do the manoeuvres and felt like a real midwife after 23 years and breech births breech skills in Belfast, Walker, S., Parker, P., Scamell, M., 2017. Expertise in physiological breech October 2017 my hands didn't shake once! Thanks so much your skills helped save that baby's life. birth: A mixed-methods study. Birth. doi:10.1111/birt.12326

88 89 What is the magic number? Mechanisms of sustainability

* Walker, S., Scamell, M., Parker, • There is none – context dependent P., 2016. Standards for maternity • Affinity care professionals attending • About 10-13 for competence planned upright breech births: A Delphi study. Midwifery 34, 7–14. – “joy, love and beauty” • About 3-6 per year to maintain competence • About 20 is associated with expertise • Visibility • Triangulated with qualitative data (3-30 upright breeches) – Labour Ward, Community, Women – More experience = more identity, referrals – Most experience = higher responsibility • Relationship – Continuity throughout the care Achieving these numbers in the UK is only possible in contexts where breech pathway The Belfast Royal Victoria breech birth is supported, and service is provided with a ‘breech team’ approach, team: Obstetricians Niamh McCabe within a recognised care pathway. – Some on-call element and Janitha Costa, and Breech Specialist Midwife Jacqui Simpson

Breech = physiological What does a breech specialist do? • Counselling • Presentation diagnosis by USS Teaching breech skills as part of • ECV/moxibustion obstetric emergencies training • Support other maternity staff at breech courses reduces likelihood of births, planned or unplanned subsequent attendance at actual • Teach updates at mandatory events and for students vaginal breech births. • Reflective review after breech births / study group Effectiveness of vaginal breech birth training strategies: an integrative • Risk management related to breech / review of the literature. Walker, Breslin, Scamell, and Parker (2017) Birth, Audit 44:101-9. Picture credit: Dr Jacque Gerrard, RCM • Research and conferences © 2018 breechbirth.org.uk 14 © 2018 breechbirth.org.uk 16

90 91 Continuity within a recognised, accessible care pathway

20 months: 27/137 undiagnosed (20%)

Approx 1:135 women

18 cesarean sections 9 vaginal births 67% 33%

22 MLC 81%

8 diagnosed after multiple VEs 30%

92 93 Developing local specialists Mechanisms of alienation • Specialists support the wider team – 3-6 VBBs per year* • Fear

• The wider team supports the specialists • Under-used experience • Team approach – midwife and doctor, not either/or • Professional hierarchy • Realistic and sustainable

Learning breech skills

* Walker, S., Scamell, M., Parker, P., 2016. Standards for Blog: ‘Breech birth together in Inca, Mallorca maternity care professionals attending planned upright breech team work’ births: A Delphi study. Midwifery 34, 7–14. © 2018 breechbirth.org.uk 21 © 2018 breechbirth.org.uk 23

Committed to collaboration & physiological birth Summary

Dr Andrew Bisits: “Each breech birth was a • Expertise develops in social-clinical roles, gold mine for learning about normal birth.” which expand as experience grows: Normal Birth Conference, Sydney, 2015 clinician, mentor, specialist, expert

• Dr Bootstaylor & SeeBaby Midwifery Dr Bootstaylor teaching breech skills • Enabled specialist teams are the foundation – Atlanta, Georgia, USA in Atlanta, Georgia • VBAC, twin births, water births of a safe and sustainable service • Collaboration with women, doulas, midwives • Willingness to work to the rhythm of physiological • Not because they do everything but birth (including being on-call) because they are able to provide high • Breech births = low CS rates quality teaching out of experience

94 95 Further details:

initial Please initial Please Name and contact information of the birthing person (if not available, please supply a copy of the consent you have to share the video):

(Can be (Can

line Name and contact information of the midwife/doctor (if not supplied, we will ensure they are not identifiable, including muting voices):

and/or teaching

for teaching purposes

I would like the following names to be credited with the video/photographs: Date: ______

, illustration Names: Date: ______Date: ______publicly

______line research -

access) ______None. Please ensure that the video/photographs are completely CIC , breechbirth.org.uk

anonymised. used in print orsubscription accesson-

, strictly controlled , strictly

Language:

Signature: ______

(Limited We are committed to using the language you are most comfortable with to describe

Signature: ______Signature: ______you. We offer a ‘default’ option if you have no strong feelings, but we are Breech Birth Network comfortable and eager to adopt this according to your wishes. - - g. women or others who wish to see breech births.) breech see to wish who others or women g. .

for teaching purposes teaching for

Mother (and variations) / woman / she / her / vagina / vulva

the level(s) of sharing you feel comfortable with. You can draw an X through the box if you do not want want not do you if box the through X an draw can You with. comfortable feel you sharing of level(s) the

initial Please use: ______/forum/DVD

(if possible) Please Please

– by members of the public, e public, of the by members journals Any other instructions (e.g. for language about the birth attendants, please edit

line out the person’s face at 00:53, please mute the voices, etc.): I agree that the film / photography footage of birthmy can be professional I agree that the film / photography footage of my birth can be used on I agree that the film / photography footage of birthmy can be used for purposes to medical / midwifery audiences . Obstetrician/Midwife: Photography / Film Agreement Film / Photography Before the birth I agree that my birth may be filmed / photographed statement. the through cross and/or level, that at shared images birth your Mother’s Name: ______I understand that after the birth, I will receive copya theof film or photography footage and will be able to make an informed decision at that time about whether / how I would like the footage to be used Mother’s Name: ______After thebirth on - viewed

96 97 References for breech presentation. Patient Educ. Couns. 72, 305–310. Krebs, L., Topp, M., Langhoff-Roos, J., 1999. The relation of breech presentation at term to cerebral palsy. Br. J. Obstet. Gynaecol. 106, 943–7. Andrews, S., Leeman, L., Yonke, N., 2017. Finding the breech: Influence of breech Lightfoot, K., 2018. Women’s experiences of undiagnosed breech birth and the presentation on mode of delivery based on timing of diagnosis, attempt at effects on future childbirth decisions and expectations. University of the West of external cephalic version, and provider success with version. Birth 44, 222–229. England. Beuckens, A., Rijnders, M., Verburgt-Doeleman, G., Rijninks-van Driel, G., Thorpe, Louwen, F., Daviss, B., Johnson, K.C., Reitter, A., 2017. Does breech delivery in an J., Hutton, E., 2016. An observational study of the success and complications of upright position instead of on the back improve outcomes and avoid cesareans? 2546 external cephalic versions in low-risk pregnant women performed by Int. J. Gynecol. Obstet. 136, 151–161. trained midwives. BJOG An Int. J. Obstet. Gynaecol. 123, 415–423. Magro, M., 2017. Five years of cerebral palsy claims: A thematic review of NHS Bogner, G., Xu, F., Simbrunner, C., Bacherer, A., Reisenberger, K., 2012. Single- Resolution data. institute experience, management, success rate, and outcome after external cephalic version at term. Int. J. Gynecol. Obstet. 116, 134–137. Pergialiotis, V., Vlachos, D.G., Rodolakis, A., Haidopoulos, D., Thomakos, N., Vlachos, G.D., 2014. First versus second stage C/S maternal and neonatal Colmorn, L.B., Krebs, L., Klungsøyr, K., Jakobsson, M., Tapper, A.-M., Gissler, M., morbidity: a systematic review and meta-analysis. Eur. J. Obstet. Gynecol. Lindqvist, P.G., Källen, K., Gottvall, K., Bordahl, P.E., Bjarnadóttir, R.I., Reprod. Biol. 175, 15–24. Langhoff-Roos, J., 2017. Mode of first delivery and severe maternal complications in the subsequent pregnancy. Acta Obstet. Gynecol. Scand. 96, PROMPT, 2012. PROMPT Course Manual, 2nd ed. Cambridge University Press, 1053–1062. Cambridge. Davidson, J., 2015. The experience of vaginal breech birth: A social, cultural and Reitter, A., Daviss, B.-A., Bisits, A., Schollenberger, A., Vogl, T., Herrmann, E., gendered context. University of Brighton. Louwen, F., Zangos, S., 2014. Does pregnancy and/or shifting positions create more room in a woman’s pelvis? Am. J. Obstet. Gynecol. 211, 662.e1-662.e9. Evans, J., 2012a. The final piece of the breech birth jigsaw? Essentially MIDIRS 3, 46–49. Reitter, A., Döhring, N., Maden, Z., Hessler, P., Misselwitz, B., 2018. Is it reasonable to establish an independent obstetric leadership in a small hospital and does it Evans, J., 2012b. Understanding physiological breech birth. Essentially MIDIRS 3, result in measurable changes in quality of maternity care? Z. Geburtshilfe 17–21. Neonatol. Frye, A., 2013. Holistic Midwifery: A Comprehensive Textbook for Midwives in Reitter, A., Walker, S., 2019. Practical insight into upright breech birth from birth Homebirth Practice: Volume II, 2nd ed. Labrys Press, Portland, OR. videos: a structured analysis, in: 4th European Congress on Intrapartum Care. Hickland, P., Gargan, P., Simpson, J., McCabe, N., Costa, J., 2018. A novel and Turin, Italy. dedicated multidisciplinary service to manage breech presentation at term; 3 Rosman, A.N., Guijt, A., Vlemmix, F., Rijnders, M., Mol, B.W., Kok, M., 2013. years of experience in a tertiary care maternity unit. J. Matern. Neonatal Med. Contraindications for external cephalic version in breech position at term: a 31, 3002–3008. systematic review. Acta Obstet. Gynecol. Scand. 92, 137–142. Hofmeyr, G.J., Kulier, R., West, H.M., 2015. External cephalic version for breech Spillane, E. (2019) Obstetric Emergencies in Low Risk Settings ‘in’ Chandraharan, E. presentation at term. Cochrane database Syst. Rev. CD000083. and Arulkumaran, S. Obstetric and Intrapartum Emergencies, Cambridge Impey, L., Murphy, D., Griffiths, M., Penna, L., on behalf of the Royal College of University Press, 2nd edn. Obstetricians and Gynaecologists, 2017a. Management of Breech Presentation. Su, M., McLeod, L., Ross, S., Willan, A., Hannah, W.J., Hutton, E., Hewson, S., BJOG. Hannah, M.E., 2003. Factors associated with adverse perinatal outcome in the Impey, L., Murphy, D., Griffiths, M., Penna, L., on behalf of the Royal College of Term Breech Trial. Am. J. Obstet. Gynecol. 189, 740–745. Obstetricians and Gynaecologists, 2017b. External Cephalic Version and Toivonen, E., Palomäki, O., Huhtala, H., Uotila, J., 2012. Selective vaginal breech Reducing the Incidence of Term Breech Presentation. BJOG An Int. J. Obstet. delivery at term - still an option. Acta Obstet. Gynecol. Scand. 91, 1177–1183. Gynaecol. 124, e178–e192. Vlemmix, F., Bergenhenegouwen, L., Schaaf, J.M., Ensing, S., Rosman, A.N., Johnston, K., Heim, M., Spence, G., 2018. Royal Jubilee Maternity Services, Belfast: Ravelli, A.C.J., van der Post, J.A.M., Verhoeven, A., Visser, G.H., Mol, B.W.J., Breech Clinic Report, in: Breech Birth Network Training Day, 28 November Kok, M., 2014. Term breech deliveries in the Netherlands: did the increased 2018. cesarean rate affect neonatal outcome? A population-based cohort study. Acta Kok, M., Gravendeel, L., Opmeer, B.C., van der Post, J.A.M., Mol, B.W.J., 2008. Obstet. Gynecol. Scand. 93, 888–896. Expectant parents’ preferences for mode of delivery and trade-offs of outcomes Vlemmix, F., Kazemier, B., Rosman, A., Schaaf, J., Ravelli, A., Duvekot, H., Kok, M.,

98 99 Mol, B., 2013. 764: Effect of increased caesarean section rate due to term Become a Physiological Breech Trainer breech presentation on maternal and fetal outcome in subsequent pregnancies. Am. J. Obstet. Gynecol. 208, S321. Walker, S., 2015. Turning breech upside down: upright breech birth. MIDIRS Breech Birth Network is a registered Community Interest Midwifery Dig. 25, 325–329. Company, which means profits from our study days are Walker, S., 2013. Undiagnosed breech: Towards a woman-centred approach. Br. J. used to promote our goals: increasing the reach of high- Midwifery 21, 316–322. quality breech training and research. Walker, S., Breslin, E., Scamell, M., Parker, P., 2017a. Effectiveness of vaginal breech birth training strategies: An integrative review of the literature. Birth 44, 101–109. If you are a clinical skills teacher currently teaching breech skills within to other Walker, S., Cochrane, V., 2015. Unexpected breech: what can midwives do? Pract. Midwife 18, 26–29. members of your clinical team, within a university or a member of a breech team, we Walker, S., Parker, P., Scamell, M., 2018a. Expertise in physiological breech birth: A offer support for you to develop your confidence and mixed-methods study. Birth 45, 202–209. familiarity with the training day content. After you have Walker, S., Perilakalathil, P., Moore, J., Gibbs, C.L., Reavell, K., Crozier, K., 2015. attended a study day as a participant, contact Emma Standards for midwife practitioners of external cephalic version: A Delphi study. Midwifery 31, e79–e86. Spillane, our Training Co-ordinator Walker, S., Reading, C., Siverwood-Cope, O., Cochrane, V., 2017b. Physiological ([email protected]). We can offer up to breech birth: Evaluation of a training programme for birth professionals. Pract. £150/year of paid expenses for you to attend further Midwife 20, 25–28. training days as an assistant teacher. Walker, S., Sabrosa, R., 2014. Assessment of fetal presentation: Exploring a woman-centred approach. Br. J. Midwifery 22, 240–244. Walker, S., Scamell, M., Parker, P., 2018b. Deliberate acquisition of competence in Most people begin by helping with the manual physiological breech birth: A grounded theory study. Women and Birth 31, manoeuvres, and then beginning to present content, e170–e177. such as the mechanisms or one manoeuvre at a time. Walker, S., Scamell, M., Parker, P., 2016a. Standards for maternity care professionals attending planned upright breech births: A Delphi study. Midwifery If you are confident presenting the content, after a period of time there may be an 34, 7–14. opportunity for you to become an independent study day provider under the Breech Walker, S., Scamell, M., Parker, P., 2016b. Principles of physiological breech birth Birth Network umbrella. But many skills teachers simply use this opportunity to practice: A Delphi study. Midwifery 43, 1–6. Whyte, H., Hannah, M.E., Saigal, S., Hannah, W.J., Hewson, S., Amankwah, K., update every year or so and teach mostly within their local context. Cheng, M., Gafni, A., Guselle, P., Helewa, M., Hodnett, E.D., Hutton, E., Kung, R., McKay, D., Ross, S., Willan, A., 2004. Outcomes of children at 2 years after planned cesarean birth versus planned vaginal birth for breech presentation at term: the International Randomized Term Breech Trial. Am. J. Obstet. Gynecol. Research Support 191, 864–71. Yigit, M.B., Kowalski, W.J., Hutchon, D.J.R., Pekkan, K., 2015. Transition from fetal to neonatal circulation: Modeling the effect of umbilical cord clamping. J. Have you done research related to physiological breech birth that you would like to Biomech. 48, 1662–1670. present at a conference or at one of our study days? We may be able to support you

with some expenses for these purposes as well. To enquire, e-mail our Director, Shawn Walker ([email protected]), with an abstract of your research and how you would like our support to share it.

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